REFRACTION DISORDER

PURNAMANITA SYAWAL
BKMM MAKASSAR

REFRACTION
Process to measure a patients
refractive error
Determine optical correction needed to
focus light rays from distant & near
objects onto retina
Provide the patient with clear &
comfortable vision

REFRACTIVE MEDIA
1. KORNEA
- Contribute 2/3 of refracting power
of the eye 43 D
2. THE LENS
- Contribute 1/3 of refractive power of
the eye 20 D
- Total convergence power of the eye
58,7 D (not 43 20 D) due to the distance between the
cornea & the lens (deep of anterior chamber) that
substract 4 D ( 63 4 D = 58,7 D)

REFRACTIVE MEDIA, cont..

3. THE PUPIL
- Reduce amount of light
enters the eye
- Decrease aberrations
- Increases the depth
of focus when costricting

REFRACTIVE STATES OF THE EYE

Emmetropia
Ammetropia
1. Myopia
2. Hyperopia
3. Astigmatism

EMMETROPIA
Emmetropia (normal vision) Eye focusing power perfectly
matched to globe length
Image focused precisely on retina
Normal vision confers focal length of infinity

AMMETROPIA
Mismatch between the optical power & length of the eye
Etiology :
Ammetropia

Refractive apparatus
(cornea and lens) is

Axial length is

Axial myopia

Normal

Too long

Refractive myopia

Too strong

Normal

Axial hyperopia

Normal

Too short

Refractive hyperopia

Too weak

Normal

MYOPIA
(Nearsighness)
Focused image in front of the retina

CAUSE OF MYOPIA
1. Causes Autosomal dominant inheritance
Mild Myopia (-0.5 to -2.0 D) by age 5 to 8 years
Moderate Myopia (-2.0 to -5.0 D) by age 8-14
Severe Myopia (<-6.0 D) by age 20 to 28 years
2. Environmental Cause (Prolonged reading, close
work)
Mild Myopia (-0.5 to -2.0 D) by age 8-14 years
Moderate Myopia (-2.0 to -5.0 D) by age 20-28

CAUSE OF MYOPIA cont..

1. Structural or axial myopia Anteroposterior (AP) diameter longer than
normal (N)
2. Curvature myopia AP diameter is
normal, but corneal curvature steeper
than N
3. Increased index of refraction
4. Anterior displacement of the lens

SYMPTOMS OF MYOPIA
Blurred vision for distance
Squint (due to blepharospasm- like action to act as
a pinhole)
Headache
Myopic school usually detected at 9-10 yo,
increase till mid-teens (stable at S-5,00D)
Progressive myopia, increase up to -4 D/year,may
reach up to -10 D or 20 D predispose to retinal
detachment & primary open angle glaucoma

HYPEROPIA
Hyperopia (Farsightedness) Normal in
infants (+0.50 to +2.50 Diopters)
Vision normalizes by age 5 to 8 years old

Light rays focus behind cornea

Cornea too flat or lens too weak for globe
Near objects not seen clearly

Correction: Convex lenses (convergent,

plus power)

CAUSE OF HYPEROPIA
1. Structural or axial hyperopia AP
diameter shorter than N
2. Curvature hyperopia
3. Index of refraction hyperopia

 LATENT HYPEROPIA : part of the refractive

error completely corrected by accomodation,
only be measured by cycloplegic refraction &
not manifest refraction
MANIFEST OR ABSOLUTE HYPEROPIA :
part of hyperopia not corrected by
accomodation
FACULTATIF HYPEROPIA = MANIFEST
HYPEROPIA ABSOLUTE HYPEROPIA

HYPEROPIA
Ex : Patient 25 yo, visual acuity 6/20
- Correction with S + 2,00 D 6/6
- Correction with S + 2,50 D 6/6
- Correction with cycloplegik S +5,00 D 6/6
So, this patient have :
- Absolute hyperopia S +2,00 D
- Manifest hyperopia S + 2,50 D
- Facultatif hyperopia = S +2,50 S+2,00 = S+0,5D
- Latent hyperopia S +5,00 D S +2,50 D =
S +2,50 D

SYMPTOMS OF HYPEROPIA
Blurred vision for distance
Frontal headache prolonged use of near
vision
Asthenopia : fatigue, burning eye sensasion &
periorbital pain when fixing at an object for
prolonged periods of time
Light sensitivity
Decreased in near visual acuity at a younger
age than in emmetropic eyes

ASTIGMATISM
Astigmatism
Non-spherical
corneal surface
Parts of surface
(meridians) are
steeper than others
Objects blurry at any
distance
The curvature of the optical systrm varies in different
meridians thus refracting the incident ligth differently
in those meridians

ASTIGMATISM
With the rule astigmatism : the vertical meridians is
steeper
Againts the rule : the horizontal meridians is steeper
Regular astigmatism : Principles meridians are 90
apart
Irregular astigmatism : Principles meridians are not
90 apart, cant be completely corrected by
spectacles,
but with contact lens

REGULAR ASTIGMATISM
SIMPLE ASTIGMATISM

Lens correction C -

Lens correction C +

REGULAR ASTIGMATISM
COMPOUND ASTIGMATISM

Lens correction S (-) C (-)

Lens correction S (+) C (+)

REGULAR ASTIGMATISM
MIXED ASTIGMATISM

Lens correction

S (-) C (+)
S (+) C (-)

SYMPTOMS OF ASTIGMATISM

Blurred vision for far and near

Squint (for pinhole effect)
Asthenopic symptoms
Frontal headaches
Tilting of the head

TRANSPOSITION OF SPHEROCYLINDRICAL
NOTATION
TRANSPOSITION OF SPHEROCYLINDRICAL NOTATION
New sphere = old sphere + old cylinder
New cylinder = old cylinder, but with opposite sign
New axis = old axis changed by 90
Ex : - 0,75 + 0,50 x 180
Ex :

-0,25 -0,50 x 90

MANAGEMENT REFRACTIVE ERROR

1. Management: Refractive Error Correction
Non-Surgical Options (Myopia : concave
lens, hyperopia : convex lens, Astigmatism :
cylinder lens)
- Eye Glasses
- Contact Lenses
2. Refractive surgery
- Laser In Situ Keratomileusis (LASIK)
- Intrastromal corneal ring (ICR)
- Phakic Intraocular Lenses

AMBLYOPIA
Decreased visual acuity of one eye (uncorrectable
with lenses) in the absence of :
- Organic eye disease insufficient enough to
explain the level of vision
- Caused by visual deprivation due to any cause
(congenital or acquired ) during the critical
period of development (up to age 8-9 yo) that
prevents the establisment of normal vision in
the involved eye

CAUSES OF AMBLYOPIA

Strabismus (most common cause)

Anisometropia
High hyperopia
Opacities : corneal scars, cataract
Optic nerve disease
Retinal disease

LOW VISION

LOW VISION (WHO)

CAUSE OF LOW VISION

Children : Optic atrophy, Congenital, cataract,
Congenital idiopathic nystagmus, Congenital
abnormalities of the brain & nerv system
Early adult life : Stargards disease, Retinitis pigmentosa
Working years: Diabetic retinopathy (>>),
Myopia,Uveitis,
Corneal dystrophies, Degenerative condition (cataract &
macular disease)
Retirement : Cataract, AMD, Glaucoma, Retinal
detachment

SYMPTOMS OF LOW VISION

Difficulty in : - reading
- recognize peoples face
- task fine detailed vision
Color vision deficits
Contrast sensitivity variably affected
Mobility not affected

LOW VISION AID

OPTICAL DEVICES :
- Microscopic glassess
- Hand magnifiers
- Stand magnifiers
- Telescope
- Closed-circuit Television
(CCTV)

LOW VISION AID

NON OPTICAL DEVICES
- Typoscope
- Standing reading book
- Writing frame
- Sunglassess lens
- Large print
- Contrast

ACCOMODATION
Accomodation mechanism the eye
changes refractive power by altering the
shape of its crystalline lens
The posterior focal point is moved
forward in the eye during
accommodation so far point moves
closer to the eye

ACCOMODATION
It is the process by the eye changes its
refractive power to focus on near
objects. It results from increased
curvature of lens due to contraction of
the ciliary muscle. The stimulus to
accomodation is a blurred retinal image.

PRESBYOPIA
Its physiologic disease in the amplitude
of accommodation associated with
aging
There is less bulging of the lens with
accommodation due to a change in the
crystalline lens that result in decrease in
the elasticity of the lens fiber or
hardening of the lens

SYMPTOMS OF PRESBYOPIA
Larger reading distance required
Inability to focus on close work
Excessive illumination required for close
work

TREATMENT OF PRESBYOPIA
Add positive lenses correction according
to age
- 40 yo : S + 1,00 D
- 45 yo : S + 1,50 D
- 50 yo : S + 2,00 D
- 55 yo : S + 2,50 D
- 60 yo : S + 3,00 D
- > 60 yo : S + 3,00 D